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THE MORTALITY OF CHILDHOOD 



Reprinted from the Quarterly Publication of the 

American Statistical Association 

March, 1918 



BY 

LOUIS I. DUBLIN, Ph.D., Statistician 
Metropolitan Life Insurance Company, New York 
, . 1918 



By Transfer 
APR 21 »» 



HBiszs 



THE MORTALITY OF CHILDHOOD.* 

There are few authoritative papers in American vital statis- 
tics on the mortality of childhood. Such as have appeared, 
moreover, have been limited for the most part to infant mor- 
tality. The other divisions of child life, i.e., the pre-school 
years and the interesting years of school life, have been vir- 
tually overlooked. The annual mortality reports of the United 
States Bureau of the Census contain the crude basic data 
on deaths at these ages but make no attempt to analyze the 
figures. The reports of the health departments of a very few 
states and cities contain references to their child mortality; 
but these are casual and scattered and have no great scientific 
value. In spite of the great interest and importance of the 
subject, there is today no phase of the whole mortality prob- 
lem in the United States for which we have less definite 
information. The public health programme for the con- 
servation of child life has undoubtedly been hampered as a 
result. 

In this paper we shall attempt to bring together the facts 
with regard to child mortality that are available for the Regis- 
tration Area of the United States and for a large group of 
insured children in the families of wage earners in the United 
States and Canada. The figures which we shall present have, 
to be sure, some limitations which we shall point out as we 
proceed. Our prime emphasis throughout will be on the 
practical uses of these data in public health work for children. 
First we shall consider the mortality of children for all causes 
of death combined and later, for the chief causes of death in 
each of the principal age periods of childhood. 

MORTALITY OF CHILDEEN : ALL CAUSES OF DEATH COMBINED. 

There are two outstanding facts with regard to child mor- 
tality: childhood is ushered in with the highest mortality 
rate and closes with the lowest rate of any divisional period 

* Paper read at the Seventy-ninth Annual Meeting of The American Statistical Association, 

1 



of life. There is, accordingly, a very rapid downward sweep 
in the death rate from age to age throughout childhood. 
The mortality during childhood should, therefore, be studied 
by single years of age; at any rate, during the first five years 
of life where the most marked changes occur from age to age. 
After the first quinquennium the mortality may readily be 
studied by five year periods of age. The following table pre- 
sents the mortality rates for male and female children under 
age 15. The figures cover the six year period 1910 to 1915 
for the expanding Registration Area of the United States. 
The populations have been estimated by means of the arith- 
metic annual increment method, using the annual estimates of 
total population for the Registration Area and distributing 
the sum by sex and age period on the basis of the distribution 
found by the 1910 Census. 

TABLE I. 

ESTIMATED POPULATION,* DEATHS AND DEATH RATES PER 1,000, EXPANDING REGIS- 
TRATION AREA OF UNITED STATES, 1910 TO 1915, AGES UNDER 15 YEARS. MALES 
AND FEMALES COMPARED. 





Males. 


Females. 


Age Period. 


Estimated 
Population. 


Deaths. 


Rate per 
1,000. 


Estimated 
Population. 


Deaths. 


Rate per 
1,000. 


(1) 


(2) 


(3) 


(4) 


(5) 


(6) 


(7) 


Under 1 

1 

2 

3 

4 


4,079,018 
3,635,315 
3,987,611 
3,940,004 
3,894,300 
19,536,248 
17,609,764 
16,870,390 


513,338 
99,319 
43,682 
27,156 
19,732 

703,227 
58,378 
38,653 


125.8 

27.3 

11.0 

6.9 

5.1 

36.0 

3.3 

2.3 


3,965,102 
3,535,519 
3,875,231 
3,884,218 
3,779,968 
19,040,038 
17,257,519 
16,603,960 


400,883 
88,256 
39,129 
24,549 
17,868 

570,685 
52,205 
35,135 


101.1 

25.0 

10.1 

6.3 

4.7 

30.0 


5 to 9 


3.0 


10 to 14 


2.1 








54,016,402 


800,258 


14.8 


52,901,517 


658,025 


12.4 







* Thanks are due to the Prudential Insurance Company and to the Census Bureau for basic data used 
in estimating these populations. 



Columns 4 and 7 in Table I show the death rates for males 
and females respectively in the several age periods. The 
highest mortality occurs, of course, under age one; 125.8 and 
101.1 for males and females respectively. These figures 
must be distinguished from the so-called infant mortality 
rates which are based on the number of births reported. A 

2 



sharp decline is observed in the death rate for the next year 
of life, between age one and two. The rates are then 27.3 
and 25.0 for males and females. The rate of decline during 
the next three years of life is less marked. At the age period 
two to three years the rates are 11.0 and 10.1 for males and 
females and in the next age period, three to four years, the 
rates reach the comparatively low figures of 6.9 and 6.3 per 
1,000 for males and females. At age four to five years the 
figures are 5.1 and 4.7 per 1,000 for males and females respec- 
tively. After age 5, the decline in the death rate is slight for 
each succeeding individual year. For the entire age period five 
to nine years the death rate is for both sexes but slightly over 
3 per 1,000. For the period 10 to 14 years the rate is not much 
more than 2 per 1,000 exposed. The minimum during the 
whole range of life is then attained. It should be noted that 
the mortality rates for males are uniformly higher than for 
females throughout the entire period of childhood, although 
it has been widely observed that the rates for the two sexes 
converge almost to identity at about age 13. After this point, 
the rates for the two sexes diverge again, the females showing 
progressively lower figures of mortality than the males. 
The general trend of the rates is, however, much the same 
for each sex. 

The rates of mortality in this table apparently are reg- 
ular in their downward course and in themselves do not 
suggest any internal technical difficulties. It is a well es- 
tablished fact, however, that the estimated population of 
the ages of childhood based upon the Census enumerations 
is far from perfect. The population under 1 year of age is 
practically always under-enumerated. The enumeration of 
population at the period one to two years is also too low as is 
indicated in columns 2 and 5 of Table I by the fact that the 
number is less than for any succeeding year in the period 1. 
to 5. Thereafter, the ages 2, 3 and 4 last birthday do not 
present substantial difficulties for our purposes. The num- 
ber of persons living declines with each succeeding year of 
age in practical accordance with the death rate at these ages. 
We may, therefore, say that the mortality rates presented in 
columns 4 and 7 are somewhat higher than they should be in 

3 



the first two years of life and that thereafter up to age 15 
they probably approach closely to the true facts of child mor- 
tality in the area covered. 

To overcome the difficulties involved in the above table 
which result from the defective enumeration of children at the 
youngest ages, we may profitably use the figures in the re- 
cently prepared United States Life Tables 1910. In these 
tables, Prof. J. W. Glover, who supervised the compilations, 
smoothed or graduated the populations recorded at the 
several age periods of childhood, following the method em- 
ployed in the preparation of the German tables for the period 
1891 to 1900. As a result of these smoothing processes, he 
obtained rates which are in all probability a closer approach 
to the true facts of mortality for the individual years of life 
in childhood than are the unadjusted figures presented in 
Table I. We present in Table II the values obtained by 
Professor Glover. They cover the three calendar years 
1909 to 1911 and relate to the original registration states as 
constituted in 1900. It should be noted that these figures 
are not central death rates but are based upon the estimated 
populations at the beginning of each age period. 

TABLE II. 
DEATH RATES AT SINGLE AGES UNDER FIVE YEARS AND BY FIVE YEAR AGE PERIODS 
THEREAFTER UP TO AGE FIFTEEN, ORIGINAL REGISTRATION STATES— 1909-1911. 
MALES AND FEMALES COMPARED. 



Age Period. 


Death Rate per Thousand. 


Males. 


Females. 


0-1 

1-2 


125.0 
28.8 
13.0 
8.1 
5.8 
39.3 
3.6 
2.4 
15.7 


103.8 
26.4 


2-3 

3-4 

4-5 


11.6 
7.6 
5.5 




33.2 


5-10 

10-15 


3.3 
2.2 
13.3 







A comparison of the rates in Tables I and II confirms the 
essential facts already brought out with regard to the mor- 
tality from all causes combined in the period of childhood. 
The death rate for males in childhood is at every point higher 

4 



than for the females. The rates of decline in mortality from 
age period to age period are also much alike in both tables. 
In fact, beginning with age 4 last birthday, the figures for 
the Registration States 1909 to 1911 and for the Registration 
Area 1910 to 1915 are very much alike. Such differences as 
appear in the two tables after age four are probably due to 
the somewhat different areas covered and to the different 
years of experience employed. The mortality rate of children 
has been somewhat on the decline since 1910 and this is shown 
in the lower rates in the later figures for the Registration Area. 
Figures prepared by us for the Registration Area for the years 
1909, 1910 and 1911 approach the Glover figures much more 
closely. 

TABLE IE. 

DEATH RATES PER 1,000. EXPANDING REGISTRATION AREA, 1910 to 1915, ORIGINAL 
REGISTRATION STATES, 1909 to 1911, AND WHITE LIVES, INDUSTRIAL DEPARTMENT, 
METROPOLITAN LIFE INSURANCE COMPANY, 1911 to 1916 COMPARED. SINGLE 
YEARS OF AGE UNDER FIVE; FIVE YEAR AGE PERIODS THEREAFTER UP TO AGE 
FIFTEEN. 





Males. 


Females. 


Age Period. 


Exp. Reg. 


Orig. Reg. 


M.L.I. Co. White 


Exp. Reg. 


Orig. Reg. 


M.L.I. Co. White 




Area 1910 


States 1909 


Ind'l 1911 


Area 1910 


States 1909 


Ind'l 1911 




to 1915. 


to 1911. 


to 1916. 


to 1915. 


to 1911. 


to 1916. 


(1) 


(2) 


(3) 


(4) 


(5) 


(6) 


(7) 


Under 1 


125.8 


125.0 





101.1 


103.8 


— 


1 


27.3 


28.8 


— 


25.0 


26.4 


— 


2 


11.0 


13.0 


— 


10.1 


11.6 


— 


3 


6.9 


8.1 


8.1 


6.3 


7.6 


7.6 


4 


5.1 


5.8 


6.0 


4.7 


5.5 


5.5 


Total under 5... 


36.0 


39.3 


— 


30.0 


33.2 


— 


5 to 9 


3.3 


3.6 


3.6 


3.0 


3.3 


3.3 


10 to 14 


2.3 


2.4 


2.3 


2.1 


2.2 


2.2 


Total under 15 . . 


14.8 


15.7 


~~ 


12.4 


13.3 





A third source of data is available in the mortality figures 
for the Industrial Department of the Metropolitan Life In- 
surance Company, which has a large exposure of children. 
Unfortunately, the actuarial* necessities of the case make a 

* The insurance experience contains no children under one year of age. This experience is also com- 
piled on the " Calendar year basis," that is, the age of the lives exposed is automatically advanced one year 
on each January 1 irrespective of the actual age of the insured at that time. This actuarial process results 
in advancing the ages of the young children so appreciably that the rates obtained for ages 1 and 2 last 
birthday are not comparable with population rates. Beginning with age 3 last birthday and thereafter 
the processes of the calendar year method balance each other at the beginning and at the end of each 
year of age and the rates obtained are, as a result, comparable with population figures for the same ages. 



comparison of the data impossible for the ages one and two 
last birthday. Thereafter, that is, beginning with age 3, the 
rates are, as is seen in columns 4 and 7 of Table III, consistent 
with those previously presented in Tables I and II and in- 
dicate that the insurance experience for the children of the 
wage earners of America approximates fairly well the mortality 
of children in the general population. Limitation is made in 
these insurance figures to white lives and the period covered 
is for the six years 1911 to 1916. The experience includes 
nearly all the states of the United States and the Provinces of 
Canada. 

PRINCIPAL CAUSES OF DEATH IN CHILDHOOD. 

Certain diseases and conditions are preeminently those of 
childhood. The causes peculiar to early infancy, the acute 
infectious diseases such as measles, scarlet fever, whooping 
cough and diphtheria, and the nutritional diseases such as in- 
fantile diarrhea and enteritis, are encountered almost entirely 
in children under 15 and have a negligible incidence beyond 
that age. On the other hand, conditions such as tuberculosis, 
all forms of pneumonia, and certain traumatisms, while more 
or less prevalent in childhood are found appreciably in other 
periods of life. Interest centers in the diseases of childhood 
because they have proved a very fruitful field of research for 
the medical investigator even if much promising work still 
remains to be carried out. A consideration of the causes of 
death in childhood is, moreover, indispensable from the stand- 
point of public health service and the prevention of disease 
generally. We shall in the following discussion consider the 
several important causes of death in each one of the age 
periods, both as to relative importance and as to the actual 
rates of mortality incidence. For this purpose we shall use 
as our basic material the returns for the expanding Registra- 
tion Area for the 6-year period from 1910 to 1915 and the 
data of the Industrial Department, Metropolitan Life Insur- 
ance Company, from 1911 to 1916. It is encouraging in con- 
nection with this proposed discussion that we are concerned 
with deaths that are, for the most part, well reported and fairly 
reliably stated as to cause. 

6 



THE FIRST YEAR OF LIFE. 

In the first year of life, a very few diseases and conditions 
account for the larger part of the mortality. Thus, the group 
of conditions included under the terms congenital debility 
and malformations and the injuries at birth together account 
for 37.6 per cent, of the total. Next in importance we find 
diarrhea and enteritis with 24.4 per cent, of the total deaths. 
The respiratory diseases which are for the most part broncho- 
pneumonia, but which literally include lobar and undefined 
pneumonia as well as bronchitis, are together responsible for 
15.5 per cent, of the deaths. We see, therefore, that three 
groups of causes alone account for nearly four-fifths of the 
total mortality of the first year of life (77.5 per cent.). 

The remainder of the mortality is distributed over a con- 
siderable number of conditions no one of which is of preemi- 
nent importance. The four important communicable diseases 
of childhood, which we shall find very prominent in our dis- 
cussion at the other age periods, are not represented to any 
large degree in the first year of life, with perhaps the excep- 
tion of whooping cough which accounts for 2.3 per cent, of 
the total deaths. The highest rate for whooping cough at any 
age is found in the initial year of life. In fact, over one- 
half of all the deaths from this disease are located in this first 
age group. A large proportion of the deaths from measles 
are also found in this first year of life. The relative signifi- 
cance of measles to all causes is not as great, however, as we 
shall find it in the later periods. Tuberculosis looms larger in 
this age period than any of the acute infectious diseases named, 
except whooping cough. About one-half of the tuberculosis 
deaths are from tuberculous meningitis. Finally, syphilis, 
which is undoubtedly under-registered at present, is noted in 
1.2 per cent, of the total deaths. In view of the high total 
mortality, we find the rate for this condition extraordinarily 
high, 137.6 per 100,000; higher in fact than is found at any 
other age period in life. Other diseases such as meningitis, 
convulsions, "other diseases of the stomach" and the "ill- 
defined diseases" are so unreliable in their certification that 
it is not desirable to refer to them in any fulness. As regis- 

7 



tration improves, they will be found more and more under 
the more definite titles referred to above. At present, how- 
ever, they account for an appreciable part of the infant mor- 
tality. 

The following table presents the important conditions in 
the first year of life, giving the percentage of each cause to 
all causes as well as the rate per 100,000 exposed at the age 
period. It was not thought necessary to give any detailed 
analysis of the figures by sex because the conditions affect 
the two sexes very similarly. Noteworthy sex differences 
appear only for whooping cough which is more prevalent as a 
cause of death among females, and for the causes peculiar to 
early infancy, such as injuries at birth, which are much more 
frequent as causes of death of male babies. This fact is in 
agreement with what is well known in obstetrical practice, 
namely, that the larger male baby is more subject to injury 
than the smaller female child. 

Since no insurances are written by the Metropolitan on the 
lives of children under one year of age no comparative in- 
surance mortality data can be quoted for the first year of life. 

TABLE IV. 

CAUSES OF DEATH IN FIRST YEAR OF LIFE. PERCENTAGE OF TOTAL DEATHS AND 
RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED STATES 
1910-1915. 



Cause of Death. 



Per cent. Total Deaths. 


Rate per 100,000. 


100.0 


11365.1 


2.3 


257.2 


1.6 


183.8 


.6 


66.4 


.8 


84.7 


1.2 


137.6 


2.5 


280.1 


8.1 


919.1 


4.9 


551.4 


24.4 


2768.6 


5.6 


637.5 


.4 


43.3 


3.5 


392.2 


1.8 


202.0 


25.9 


2946.3 


16.8 


1909.6 


9.1 


1036.7 


6.1 


696.0 


3.3 


370.1 


2.7 


301.0 



All causes 

Whooping cough 

Tuberculosis — all forms 

Tuberculosis of the lungs 

Tuberculous meningitis 

Syphilis 

Bronchitis 

Bronchopneumonia 

Pneumonia — lobar and undefined 

Diarrhea and enteritis. 

Congenital malformations — total 

Hydrocephalus 

Congenital malformations of the heart 

Other congenital malformations 

Congenital debility, icterus and sclerema — total 

Premature birth 

Congenital debility," atrophy, "marasmus. . . 
Other causes peculiar to early infancy — total. . . 

Injuries at birth. 

Other causes peculiar to early infancy 



THE SECOND TEAR OF LIFE. 

The causes responsible for the mortality during the second 
year of life present a somewhat different picture from that 
found in the earlier year. The conditions associated with 
prematurity and with the congenital defects are no longer 
present to any degree. On the other hand, diarrhea and en- 
teritis continue to play a most important part in the total 
mortality and are, in fact, the first causes of all in the second 
year of life; over one quarter of the deaths (27.3 per cent.) 
are due to this single condition. Next in importance are the 
respiratory diseases which include bronchopneumonia, pneu- 
monia lobar and undefined and bronchitis. They were re- 
sponsible for 26.4 per cent, of the deaths in the second year 
of life. Bronchopneumonia still accounts for the most part 
of these deaths. The four epidemic diseases, measles, scarlet 
fever, whooping cough and diphtheria now play a much more 
prominent part in the total mortality. Together, they account 
for 17.8 per cent, of all the deaths. Diphtheria is the most 
important of the four and reaches its highest death rate in 
any year of life. It is followed by measles with nearly the 
same rate and by whooping cough and scarlet fever in the order 
named. Tuberculosis rises in this year into a more prominent 
position, relatively, than in the first year of life but the actual 
rate per 100,000 exposed, is somewhat lower. Tuberculous 
meningitis forms over one-half of the total tuberculosis mor- 
tality. Finally, we must take the accidents into consideration, 
in this second year of life; burns alone now are responsible 
for 1.7 per cent, of the deaths with a rate of 44.1 per 100,000 
exposed and, as we shall see, this condition as well as other 
accidental causes becomes more and more prominent with the 
advancing ages of childhood. 

Males showed higher mortality rates than females in the 
second year of life for measles (154 and 142, respectively, per 
100,000), scarlet fever (47 and 41 per 100,000), diphtheria 
and croup (164 and 138 per 100,000), tuberculosis, all forms 
(156 and 141 per 100,000), tuberculous meningitis (83 and 78 
per 100,000), bronchopneumonia (393 and 358 per 100,000), 
pneumonia, lobar and undefined (266 and 232 per 100,000) 

9 



and diarrhea and enteritis (747 and 678 per 100,000). Whoop- 
ing cough showed a higher female rate (138 per 100,000). 
The male rate was 105 per 100,000. 

As before, there is an appreciable mortality registered for 
conditions such as dysentery, meningitis, "other diseases of 
the stomach" and "ill-defined diseases," which are reported 
so unreliably that no reference is made to them in our Table 
V which follows : 

TABLE V. 

CAUSES OF DEATH IN SECOND YEAR OF LIFE. PERCENTAGE OF TOTAL DEATHS AND 
RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED STATES 
1910-1915. 



Cause of Death. 


Per Cent. Total Deaths. 


Rate per 100,000. 




100.0 


2615.8 








5.7 
1.7 
4.6 
5.8 
5.7 
1.8 
3.1 
2.5 

14.4 
9.5 

27.3 
1.7 


148.1 
43.9 




120.9 
151.0 

148.2 




47.1 




80.7 




65.3 
375.9 
249.1 




713.2 




44.1 



THE THIRD YEAR OF LIFE. 

The facts of this age period show a further shift in the rela- 
tive importance of the several causes of death. The four 
chief epidemic diseases are now of the first importance, 
being responsible together for more than one fourth of the 
deaths (26.4 per cent.). Diphtheria is by far the most promi- 
nent of the four and its rate is not much less than for the sec- 
ond year of life when the mortality from all causes was more 
than twice as great. Scarlet fever while now relatively more 
prominent has much the same rate as in the preceding year; 
but the rates for measles and whooping cough have dropped 
to a little more than one third what they were in the second 
year. The respiratory conditions including the same diseases 
listed in the previous discussion, are now responsible for 22.0 
per cent, of the total mortality. Bronchopneumonia is still 
the chief item in this list. Diarrhea and enteritis have de- 

10 



clined perceptibly in their proportionate incidence and even 
more so in the rate, although their importance is not yet to be 
discounted. The proportionate incidence of tuberculosis has in- 
creased also, although the rate per 100,000 has decreased to about 
one half of the previous one. Tuberculous meningitis is again 
the prominent form of tuberculosis in this year of life. Acci- 
dents and injuries, as might be expected, play an increasingly 
important part. It is at this age that children begin to mani- 
fest extraordinary curiosity about the affairs of the house- 
hold and their environment generally and indulge in all the 
activities of the runabout-child. Burns are the most impor- 
tant of the accidental causes of death, being responsible for 
4.3 per cent, of the deaths. The rate is practically the same 
as in the preceding year. We also observe that falls begin at 
this age period to become an important cause of mortality 
among children. Attention should also be directed to the 
beginning importance of typhoid fever, which now is respon- 
sible for 1 per cent, of the deaths with a rate of 10.3 per 100,000 
exposed. 

Measles shows only a slightly higher death rate for males 
than for females as does also scarlet fever, tuberculosis, all 
forms, tuberculous meningitis, and bronchopneumonia. 
Diphtheria mortality is considerably higher for males (136 
per 100,000) than for females (122 per 100,000). Pneumonia, 
lobar and undefined shows a male rate of 98 which may be 
compared with a female rate of 89 per 100,000. Diarrhea and 
enteritis shows rates of 143 and 130 per 100,000 for males and 
females respectively in the third year of life. Burns show a 
male mortality rate of 49 and a female rate of 40 per 100,000. 
Traumatism by fall shows, comparatively, a rate of 11 for 
males and 7 per 100,000 for females. 

Several conditions such as dysentery, meningitis, acute 
nephritis, acute poisonings and ill-defined diseases are regis- 
tered in significant proportions but their rates, in view of 
the declining total mortality, are not large enough to warrant 
any extended treatment, especially in view of the indefinite 
character of most of these titles or of their unreliability as 
statements of cause of death. The chief facts for the third 
year of life are shown in Table VI. 

11 



TABLE VI. 

CAUSES OF DEATH IN THIRD YEAR OF LIFE. PERCENTAGE OF TOTAL DEATHS AND 
RATES PER 100,000, EXPANDING (REGISTRATION AREA OF THE UNITED STATES 
1910-1015. 




THE FOURTH YEAR OF LIFE. 

The fourth year of life witnesses another marked reduction in 
the total mortality rate from the figure of the preceding year. 
From this age onward the reduction in the mortality from all 
causes is comparatively slight. The four epidemic diseases 
together are now responsible for about one third of the total 
mortality. The chief of these four is diphtheria which ac- 
counts for over a sixth of the deaths in both the population 
and insurance experiences. The respiratory diseases and 
conditions are of less importance in the fourth year of life than 
in the preceding age, both in relation to all causes of death 
and to the exposure. They constitute the second important 
group with 16.8 per cent, of the deaths among children in the 
general population and 18.1 per cent, among insured children. 
In both experiences, respiratory diseases and conditions com- 
bined have approximately the same number of deaths as the 
single cause of death, diphtheria. Bronchopneumonia is 
still the most commonly reported form of respiratory disease, 
although lobar pneumonia shows an increasing ratio of impor- 
tance in the mortality from these conditions. Tuberculosis, 
all forms, has a slightly higher relative incidence than in the 
earlier year; the rate is one third lower, however. Tuberculous 

12 



meningitis is still the important form of this disease, in both 
the population and insurance experiences. 

Diarrhea and enteritis, a group of diseases and conditions 
which constitute the fourth cause as to prominence among 
all deaths in the fourth year of life, are now much less signifi- 
cant than in the preceding ages. They are recorded in 7.3 
per cent, of the deaths among population children with a rate 
of 48.4 per 100,000, and in 8.0 per cent, of the deaths of 
insured children at a rate of 62.7 per 100,000 exposed. Acci- 
dents and injuries show an increase in the proportion of all 
deaths, but with only a slight decrease in the rate per 100,000 
of population. Burns are by far the most prominent acci- 
dental cause of death. Traumatism by fall is recorded in 
about 1 per cent, of the deaths. Vehicular accidents, of which 
automobile accidents are a prominent element, assume promi- 
nence in this age with 1.6 per cent, of the total deaths in both 
the population and insurance experience. 

Typhoid fever shows a similar rate of mortality in this age 
as in the preceding one, although its relative importance is 
somewhat increased. 

In making these comparisons between the mortality of 
children in the general population and in the insurance experi- 
ence, it must be borne in mind continually that the population 
embraces a considerable rural area while insured children live 
for the most part in large cities, where the factors of congestion 
of population affect the incidence and fatality of certain of the 
epidemic diseases. Traffic conditions likewise tend to in- 
crease the mortality rate from accidents of city children. 

The mortality rates of the two sexes deserve passing com- 
ment. Measles, scarlet fever, tuberculosis and bronchopneu- 
monia show no very significant differences in the mortality 
rates of males and females in the fourth year of life. Diph- 
theria, however, continues to show a considerably higher rate 
for males, 120 per 100,000, than for females, 105 per 100,000. 
Pneumonia, lobar and undefined was indicated at a rate of 
54 per 100,000 for males and only 47 per 100,000 for females. 
Diarrhea and enteritis had a rate of 52 for males and 45 for 
females. Traumatism by fall showed a higher rate for males, 
8 per 100,000, than for females, 5 per 100,000, as did also 

13 



automobile accidents and injuries where the male rate was 4 
per 100,000 and the female rate was only 2 per 100,000. 

The ill-defined causes of death and a number of others which 
are in effect terminal conditions of the acute infections are 
present in this age group as before, but find no proper place 
in our Table VII which follows: 

TABLE Vn. 

CAUSES OF DEATH IN FOURTH YEAR OF LIFE. PERCENTAGE OF TOTAL DEATHS AND 
RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED STATES 
1910-1915, AND METROPOLITAN LIFE INSURANCE CO., INDUSTRIAL DEPARTMENT, 
WHITE LIVES, 1911 TO 1916. 



Cause of Death. 



Per cent. Total Deaths. 



Area. M.L.I. Co. 



Rate per 100,000. 



Reg. Area. M.L.I. Co, 



All causes 

Typhoid fever , 

Measles 

Scarlet fever , 

Whooping cough , 

Diphtheria and croup 

Tuberculosis — all forms 

Tuberculosis of the lungs 

Tuberculous meningitis 

Bronchitis 

Bronchopneumonia 

Pneumonia — lobar and undefined. 

Diarrhea and enteritis 

Burns 

Traumatism by fall 

Total vehicular accidents 



100.0 



1.5 

4.4 
7.0 
3.2 
17.0 
7.7 
2.3 
4.0 
1.4 
7.8 
7.6 
7.3 
5.9 
1.0 
1.6 



100.0 



1.4 
5.7 
5.8 
3.5 
18.1 
7.2 
1.7 
4.4 
1.7 
9.3 
7.1 
8.0 
5.0 
1.1 
1.6 



10.2 
29.1 
46.1 
21.1 
112.2 
50.5 
15.3 
26.7 

8.9 
51.4 
50.5 
48.4 
38.8 

6.8 
10.5 



788.8 



11.1 
45.3 
46.1 
27.9 
147.2 
56.9 
13.0 
34.7 
13.2 
73.0 
56.1 
62.7 
39.4 
8.4 
12.9 



THE FIFTH YEAR OF LIFE. 

In the last of the first five years of life, the total mortality 
rate has again declined from that of the preceding year. 
The changes of the relative importance of the individual 
conditions are also few and unimportant both in the insurance 
and general population experiences. In fact much the same 
picture is presented by Table VIII as in the preceding one; our 
discussion of this age is, therefore, necessarily brief. Atten- 
tion need be directed only to the increasing prominence of 
typhoid fever, to the appearance for the first time of appen- 
dicitis as a condition deserving comment, and to the presence 
of the organic heart diseases which are the cause of 1.6 per 
cent, of all the deaths in the fifth year of life among population 

14 



children, and for 1.2 per cent, among deaths of insured chil- 
dren. It is possible, of course, that the latter diseases as 
well as acute nephritis which we have not included in our 
table but which is also reported in 1.3 per cent, of the deaths 
of population children, are in large measure the sequelae of 
the epidemic diseases. Reference should also be made to 
the increasing incidence of the vehicular accidents which are 
in this age period responsible for 2.5 per cent, of the total 
mortality in both experiences. The automobile accidents 
are by far the most prominent of the individual conditions 
under this head. 

Apart from a few conditions, there are no very significant 
differences between the population and insurance experiences 
among children in this year of life. 

table vm. 

CAUSES OF DEATH IN FIFTH YEAR OF LIFE. PERCENTAGE OF TOTAL DEATHS AND 
RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED STATES 
1910-1915, AND METROPOLITAN LIFE INSURANCE CO., INDUSTRIAL DEPARTMENT, 
WHITE LIVES, 1911 TO 1916. 



CauBe of Death. 



Per cent. Total Deaths. 



Reg. Area. M.L.I. Co, 



Rate per 100,000. 



Reg. Area. M.L.I. Co, 



All causes 

Typhoid fever 

Measles 

Scarlet fever 

Whooping cough 

Diphtheria and croup 

Tuberculosis — all forms 

Tuberculosis of the lungs 

Tuberculous meningitis 

Organic diseases of the heart 

Bronchitis 

Bronchopneumonia 

Pneumonia — lobar and undefined. . . 

Diarrhea and enteritis 

Appendicitis 

Burns 

Traumatism by fall 

Total vehicular accidents 

Automobile accidents and injuries. 



100.0 



2.2 
3.5 
7.6 
2.4 
18.8 
7.7 
2.5 
3.8 
1.6 
1.1 
6.0 
6.8 
5.0 
1.4 
5.7 
1.1 
2.5 



100.0 



2.0 
4.5 
7.4 
2.5 
22.2 
7.0 
1.7 
4.1 
1.2 
1.2 
6.4 
6.3 
5.3 
1.0 
5.5 

.9 
2.5 

.9 



489.9 



10.6 
17.1 
37.3 
11.5 
92.3 
37.6 
12.3 
18.4 

7.8 

5.2 
29.2 
33.5 
24.5 

7.0 
28.1 

5.2 
12.3 

3.8 



576.0 



11.5 

15.6 
42.8 
14.4 
128.0 
40.4 

9.6 
23.4 

6.6 

7.0 
36.6 
36.2 
30.6 

5.5 
31.6 

5.1 
14.2 

5.3 



15 



THE SECOND QUINQUENNIUM OF LIFE AGES 5 TO 9 YEARS. 

The second five years of life are characterized by extremely 
low mortality rates in both experiences of population and 
insured children. The interrelations between the several 
causes of death are in the main different from those we have 
previously described. We are now concerned with a very 
much larger list of diseases and conditions, a considerable 
number of which have made their appearance for the first 
time in any appreciable degree. These include certain organic 
conditions which are indicative of degenerative processes. 
Of the epidemic diseases of childhood only two now merit 
attention, scarlet fever and diphtheria. Measles and whoop- 
ing cough play comparatively minor parts in the total mortality 
between ages 5 and 9. Typhoid fever has increased to a respec- 
table figure, 3.7 per cent, of all deaths and a rate of 11.0 per 
100,000 for general population children, and 2.9 per cent, and a 
rate of 10.0 per 100,000 for insured children. Tuberculosis 
becomes a little more important as a factor of mortality in this 
period and from now on will be found to increase continuously 
in its rate for a long period of years. Tuberculous meningitis 
for the first time in childhood becomes a less important form 
of this disease than pulmonary tuberculosis. Pneumonia, all 
forms, is still among the more prominent causes of death; 
and bronchopneumonia has fallen much below lobar pneumonia 
in its incidence. Appendicitis has approximately the same 
mortality rate as typhoid fever in both general population 
and insurance experiences. The accidents and injuries are 
prominent and such conditions as falls, accidental drowning 
and the vehicular accidents, chief of which are the automobile 
accidents, demand more and more of our attention. 

Concerning the organic conditions referred to above, we 
must direct especial attention to acute articular rheumatism, 
diabetes, acute endocarditis, organic diseases of the heart 
and acute nephritis and Bright's disease. Some of these are 
undoubtedly idiopathic but most of them, probably, are either 
the immediate or ultimate sequelae of the epidemic diseases 
of childhood. 



16 



TABLE EX. 

CAUSES OF DEATH IN SECOND QUINQUENNIUM OF LIFE. PERCENTAGE OF TOTAL 
DEATHS AND RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED 
STATES 1910-1915, AND METROPOLITAN LIFE INSURANCE CO., INDUSTRIAL DEPART- 
MENT, WHITE LIVES, 1911 TO 1916. 



Cause of Death. 



Per cent. Total Deaths. 



Reg. Area. 



M.L.I. Co. 



Rate per 100,000. 



Reg. Area. 



M.L.I. Co. 



All causes 

Typhoid fever 

Measles 

Scarlet fever 

Whooping cough 

Diphtheria and croup 

Tuberculosis — all forms 

Tuberculosis of the lungs 

Tuberculous meningitis 

Acute articular rheumatism 

Diabetes 

Acute endocarditis 

Organic diseases of the heart 

Bronchitis 

Bronchopneumonia 

Pneumonia — lobar and undefined . . . 

Diarrhea and enteritis 

Appendicitis 

Acute nephritis 

Bright's disease 

Burns 

Accidental drowning 

Traumatism by fall 

Total vehicular accidents. ......... 

Automobile accidents and injuries , 



100.0 



3.7 
2.5 
7.1 
1.2 
15.8 
8.7 
3.5 
3.4 
2.0 

.9 
1.3 
4.4 

.7 
3.5 
5.9 
2.5 
3.5 
1.4 
1.3 
2.7 
2.6 
1.3 
4.4 
1.8 



100.0 



2.9 
3.1 
6.8 
1.1 
19.8 
8.0 
2.7 
3.7 
2.3 

.5 
1.2 
4.8 

.7 
3.5 
5.1 
2.4 
2.9 

.9 
1.2 
2.7 
3.0 
1.2 
5.0 
2.5 



317.2 



11.6 

7.8 

22.5 

3.9 

50.2 

27.7 

11.2 

10.7 

6.4 

3.0 

4.3 

14.0 

2.2 

11.1 

18.7 

8.0 

11.2 

4.3 

4.3 

8.6 

8.3 

4.1 

13.9 

5.6 



348.7 



10.0 
10.9 
23.8 
3.9 
69.1 
27.8 
9.4 
12.7 
8.0 
1.7 
4.2 
16.6 
2.5 
12.2 
17.7 
8.3 
10.2 
3.2 
4.2 
9.6 
10.6 
4.2 
17.5 



THE THIRD QUINQUENNIUM OF LIFE AGES 10 TO 14 TEARS. 

This age group is characterized by the lowest mortality 
rate of any divisional period of life. In fact, for all causes of 
death combined the rate, 2.2 per 100,000 in both the popula- 
tion and insurance experience is less than the rate for some 
individual diseases in some age quinquennia. The few deaths 
which do occur in this closing age period of childhood are 
distributed over a large number of single conditions or causes 
of death, not any one of which is of great numerical importance. 
Tuberculosis is the chief cause of death in this divisional 
period of life, being responsible for 14.8 per cent, of all deaths 
in the population experience and for 12.8 per cent, in the 
insurance experience. The death rate for tuberculosis was 
32.7 per 100,000 for children in the general population and 
28.6 for insured children at this age period. Of these tuber- 

17 



culosis deaths, two thirds are of the pulmonary type. Ab- 
dominal tuberculosis appears for the first time as a significant 
cause of death, and requires notice as does also tuberculous 
meningitis. Typhoid fever has a higher rate than in the pre- 
ceding age group, but shows a lower mortality rate among 
insured than among the population children. Appendicitis, 
likewise, shows an increased prominence in both series in this 
quinquennium. 

Measles and whooping cough are no longer of any great 
consequence as causes of death in this age period. Scarlet 
fever and diphtheria give significant mortality figures for the 
last time. Between 10 and 15 years of age scarlet fever ac- 
counts for 3 per cent, of the deaths in both experiences and 
diphtheria for approximately 6 per cent, of the deaths. The 
respiratory diseases and conditions show satisfactory declines 
from the rates in earlier age periods. In this age period pneu- 
monia mortality shows its lowest rate of incidence in any age 
period of life. 

The acute infections, generally, are now replaced in signifi- 
cance by such grave diseases as organic diseases of the heart, 
acute articular rheumatism, diabetes and acute endocarditis. 
Organic diseases of the heart are responsible for 12.0 per cent, 
of the deaths among insured children and for 8.6 per cent, of 
the deaths among population children of this age group. 
Acute articular rheumatism showed a ratio of 3.0 per cent, 
of all deaths for population children and 3.4 per cent, for 
insured children. Diabetes showed a higher percentage and 
death rate among children in the general population. 

Nephritis and Bright's disease together accounted for 3.5 
per cent, of all the deaths among population children and 
for 2.9 per cent, among insured children. 

Accidents and injuries as a group occupied a prominent 
position in the total mortality, and the vehicular accidents 
as well as accidental drowning and traumatism by firearms 
are especially important as causes of death ascribed to this 
third quinquennium. 

Considered by sex, we find that males have a slightly higher 
mortality from measles, from scarlet fever, bronchopneumonia, 
and pneumonia, lobar and undefined. For traumatism by fall 

18 



males show a rate of 4.8 per 100,000 which may be compared 
with a figure of 1.3 for females in the general population. 
Automobile accidents and injuries had a rate of 5.5 per 100,000 
for males and 1.0 per 100,000 for females in the third quinquen- 
nium of life. 

The facts available for this age group in both the population 
and insurance experience are shown in the following Table X. 

TABLE X. 

CAUSES OF DEATH IN THIRD QUINQUENNIUM OF LIFE. PERCENTAGE OF TOTAL 
DEATHS AND RATES PER 100,000, EXPANDING REGISTRATION AREA OF THE UNITED 
STATES 1910-1915, AND METROPOLITAN LIFE INSURANCE CO., INDUSTRIAL DEPART- 
MENT, WHITE LIVES, 1911 TO 1916. 



Cause of Death. 



Per cent. Total Deaths. 



Reg. Area. M.L.I. Co 



Rate per 100,000. 



Reg. Area. 



Mi J. Co. 



All eauses 

Typhoid fever 

Measles 

Scarlet fever 

Whooping cough 

Diphtheria and croup 

Tuberculosis — all forms 

Tuberculosis of the lungs 

Tuberculous meningitis 

Abdominal tuberculosis 

Acute articular rheumatism 

Diabetes 

Acute endocarditis 

Organic diseases of the heart 

Bronchitis 

Bronchopneumonia 

Pneumonia — lobar and undefined . 

Diarrhea and enteritis 

Appendicitis 

Acute nephritis 

Bright's disease 

Burns 

Accidental drowning 

Traumatism by firearms , 

Traumatism by fall , 

Total vehicular accidents 



100.0 



6.4 
1.0 
3.0 

.2 
5.6 
14.8 
10.2 
2.2 
1.0 
3.0 
2.2 
1.8 
8.6 

.3 
1.4 
5.3 

.9 
6.3 
1.2 
2.3 
1.0 
4.4 
1.9 
1.4 
4.4 



100.0 



5.8 

.7 
3.0 

.1 
6.4 
12.8 
8.5 
2.1 

.8 
3.4 
1.6 
1.9 
12.0 

.3 
1.3 
4.5 

.9 
6.3 

.8 
2.1 
1.1 
6.0 
1.3 
1.3 
5.3 



220.4 



14.2 

2.2 

6.6 

.5 

12.2 

32.7 

22.4 
4.7 
2.2 
6i.5 
4.9 
3.1 

18.9 

.7 

3.2 

11.7 
2.1 

13.8 
2.7 
5.0 
2.2 
9.7 
4.1 
3.1 



224.0 



12.9 

1.6 

6.7 

.3 

14.2 

28.6 

19.0 
4.7 
1.7 
7.7 
3.6 
4.2 

27.0 

.6 

2.9 

10.1 
2.1 

14.1 
1.8 
4.7 
2.4 

13.4 
2.9 
3.0 

11.9 



SUMMARY OP MORTALITY OF CHILDHOOD. 

We have presented in some detail the main facts of mor- 
tality in each of the age classes of childhood. We may now 
summarize our discussion for the entire period, considering 
primarily the characteristics of the principal groups of causes 
of death affecting children. 

We may conveniently group these causes of death under 
six heads as follows: 

19 



i. Causes indicative of prematurity, of congenital debility 
or of injury at birth. 

ii. Diseases and conditions of the digestive tract. 

iii. Diseases and conditions of the respiratory system. 

iv. The principal epidemic diseases of childhood: measles, 
scarlet fever, whooping cough and diphtheria. 

v. Accidents and injuries. 

vi. Important infectious and organic diseases of miscel- 
laneous order. 

I. CAUSES INDICATIVE OF PREMATURITY, OF CONGENITAL DEBIL- 
ITY OR OF INJURY AT BIRTH. 

These causes of death affect, primarily, the first year of 
life when they are responsible for more than three eighths of 
the mortality. Only congenital malformations appear to 
any extent among the deaths after the first year. Yet so 
great is their importance numerically during infancy that 
close to a quarter of all the deaths under age fifteen are found 
registered under these titles. 

These causes, for the most part, reflect the influence of 
prenatal conditions on the child. The health of the mother, 
her habits and the character of her employment during preg- 
nancy play a large part in this phase of infant mortality. 
Parental alcoholism and syphilis are perhaps the most potent 
single factors, although unskilled obstetrical care is still to be 
considered important. 

Male infants show uniformly a higher incidence from these 
conditions. 

II. DISEASES AND CONDITIONS OF THE DIGESTIVE TRACT. 

It is advisable to consider only the diarrheal diseases of 
children, although a number of other, but numerically insig- 
nificant, conditions could properly be included under this 
head. The diarrheal diseases account for a little more than 
20 per cent, of the total mortality of children under 15 years 
of age. They are of great importance throughout the entire 
range of childhood but the highest mortality is found in the 
first year of life. In the second year of life the rate is reduced 
to about one-quarter of what it was in the first year although 

20 



it is the first of all causes in its relative importance at this 
age. For each age thereafter, there is a progressive decline 
up to and including the age period 10 to 14 years, when the 
minimum death rate for childhood is reached. Throughout 
the years of childhood, the male death rate from diarrheal 
diseases is higher than the female death rate, the excess of 
male over female mortality being more pronounced at the 
very early years of childhood. 

III. DISEASES AND CONDITIONS OF THE RESPIRATORY SYSTEM. 

This group includes bronchopneumonia, pneumonia — lobar 
and undefined, and bronchitis. Together, these diseases ac- 
count for 16.4 per cent, of all the deaths in the ages of child- 
hood. Bronchopneumonia is by far the most important of 
these causes of death with 8.3 per cent, of the total mortality 
followed by pneumonia — lobar and undefined with 5.9 per 
cent, and by bronchitis with 2.1 per cent, of all the deaths. 
The highest death rate for the diseases of the respiratory sys- 
tem is recorded in infancy. The mortality declines with each 
succeeding age period until the minimum is found in the years 
10 to 14. Significant differences in the mortality of the two 
sexes appear only for the first 4 or 5 years of life. For the 
ages of childhood after 5 years, the sex differences are not very 
significant. 

IV. THE PRINCIPAL EPIDEMIC DISEASES OF CHILDHOOD : MEASLES, 
SCARLET FEVER, WHOOPING COUGH AND DIPHTHERIA. 

These four conditions account for 10.7 per cent, of all the 
deaths recorded in our study of this 15 year period of life. 
Diphtheria is the most important of the four followed by 
whooping cough, measles and scarlet fever in the order named. 
These diseases vary somewhat in their points of maximum 
incidence. The highest mortality from whooping cough is 
found in infancy. Measles and diphtheria show their highest 
mortality rates in the second year of life and scarlet fever in 
the third year of life, that is, between 2 and 3 years of age. 
After their points of maximum incidence, these diseases de- 
cline, although not at the same rate, to a minimum point in 
the age period 10 to 14 years. Scarlet fever has a mortality 

21 



rate in the second, third and fourth years of life which varies 
but little from the maximum point of 49.7 per 100,000 in 
the third year of life. The other three of these chief epidemic 
diseases of childhood seem to rise sharply to a maximum and 
to decline fairly rapidly after the point of highest incidence. 
Only diphtheria and scarlet fever continue to show serious 
mortality rates after the period of childhood. 

With the exception of whooping cough, the death rate for 
these diseases is higher for males than for females during the 
first five years of life. After the fifth year of life the mortality 
rates of measles, scarlet fever and diphtheria for the two sexes 
are not markedly different. For whooping cough the mortality 
rates are considerably higher for females throughout the entire 
period of childhood but the percentage of excess female mor- 
tality is greatest in the third year of life. 

V. ACCIDENTS AND INJURIES. 

Accidents and injuries are a significant group of causes of 
death in childhood. Burns, falls, automobile and other 
vehicular accidents and injuries, drowning and accidental 
poisonings constitute the chief single causes of accident 
mortality at these ages. Burns account for an appreciable 
percentage of the total mortality from the second to the fifth 
year of life. Falls play an important part in the deaths be- 
tween the second and fourth year of life and show much higher 
mortality rates at each of the ages of childhood among males 
than among females. The vehicular accidents have their 
maximum incidence at the age period 5 to 9 years. The 
automobile is the chief agency in the causation of these deaths. 

VI. IMPORTANT INFECTIOUS AND ORGANIC DISEASES OF MISCEL- 
LANEOUS ORDER. 

There remain a miscellaneous group of diseases which we 
have not considered under any of the preceding five main 
groups of causes of death in children. This group includes 
the organic diseases of the heart, the acute and chronic 
diseases of the kidneys, acute articular rheumatism, acute 
endocarditis, diabetes^ appendicitis, and tuberculosis, espe- 
cially tuberculous meningitis. 

22 



The organic diseases of the heart first begin to assume 
prominence in the fourth year of life and increase in frequency 
up to the age period 10 to 14 years where we record the maxi- 
mum rate in childhood. Diseases of the kidneys likewise are 
of significance first in the fourth year of life. The maximum 
rate for acute nephritis is found between 3 and 4 years, and 
the minimum between 10 and 14 years. These deaths in 
many instances follow the acute infectious diseases, scarlet 
fever chiefly. Bright's disease is of some importance in the 
second and third quinquennia of childhood. Chronic Bright's 
disease in childhood is also closely associated with the acute 
infectious diseases of the earlier ages but the number of 
deaths continues to be important in the second and third 
quinquennia. Acute endocarditis and acute articular rheu- 
matism may be considered together, because of the frequent 
clinical association of the two conditions. We record a signifi- 
cant rate of mortality between ages 5 and 9 years from both 
of these conditions. Appendicitis is an important cause of 
mortality beginning with the fourth year of life and increases 
in incidence throughout childhood. 

Tuberculosis is a leading cause of death throughout all the 
ages of childhood. The rate is highest in the first year of 
life; it decreases to a minimum in the period 5 to 9 years, and 
rises thereafter. Tuberculous meningitis is the chief form of 
tuberculosis in the first ten years of fife. Tuberculosis of the 
lungs shows its minimum rate in the period 5 to 9 years, but 
beginning with the quinquennium 10 to 14 years, the mortal- 
ity for tuberculosis of the lungs rises to first importance and 
continues to hold its place as the leading cause of death for 
several age periods thereafter. 

CONCLUSIONS AND RECOMMENDATIONS. 

The following conclusions and recommendations suggest 
themselves from this analysis of the mortality statistics of 
childhood. 

There is opportunity and need for concentrating the efforts 
of the public health movement upon the further reduction of 
mortality in childhood. The work of community health 
agencies during the past twenty years has shown clearly the 

23 



large possibilities for life conservation when directed at the 
preventable causes of infant and child mortality. The re- 
duction of infant mortality has become a definitely established 
part of the public health programme. Much additional 
saving can be accomplished by attacking especially the group 
of diseases which we have included under the heading of pre- 
maturity, congenital debility and malformations, etc. The 
extension of effective prenatal work and the provision of 
greater facilities for competent obstetrical and nursing aid in 
childbirth will accomplish very material reductions in mor- 
tality from this group of causes which constitute so large an 
element in the destruction of child life. Practical experience 
in prenatal work in a number of cities, especially in Boston, 
Massachusetts, has already demonstrated the exceptional 
opportunities for the saving of maternal and infant life which 
await the broadening public health programme in the United 
States. 

The so-called "pre-school" years of childhood have as yet 
received very little attention from the life conservation move- 
ment. Much preventable mortality is in evidence at these 
ages beyond infancy and under the school years. Sickness 
and mortality from the acute epidemic infections, and espe- 
cially from the more serious complications of these diseases, 
are still in evidence and constitute a challenge to our best 
efforts for their control. Diphtheria is still a very grave men- 
ace to child life at these pre-school years. The extensive 
development of child welfare clinics, patterned very much 
after infant welfare stations, seems to be indicated by the facts 
of our inquiry. While their primary function should be, per- 
haps, the control of nutritional diseases, the work of such 
clinics may well result in a reduction of the sickness and mor- 
tality rate of the acute epidemic diseases through an increase 
in the physical resistance of children and by the dissemination 
of hygienic knowledge to mothers. 

The years of school life show comparatively low mortality 
rates; but even at this period, mortality is capable of still 
further reduction through additional public health welfare 
activities for children. There can be more complete coopera- 
tion between the medical authorities in schools and those 

24 




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future date. 



engaged in health conservation work outside the schools. 
School medical inspection and school nursing are still far from 
universally available for school children, especially in rural 
communities and in small cities. Where such medical and 
nursing service is available to school children, much still 
remains to be done to make this form of public health service 
more efficient and in line with practice which has stood the 
test of experience in the larger centers of population. 

Finally, we must seek earnestly to improve our sources of 
information on child life. Our available records of the num- 
ber and of the characteristics of American children according 
to single years of life are indeed faulty. This is especially 
true for the early ages in childhood, including infancy. Effec- 
tive health work is conditioned at almost every point by the 
completeness and reliability of our statistical information. 
American statisticians, including registrars of vital statistics, 
and the medical profession generally, should combine all their 
effective forces to make birth registration once and for all 
reasonably complete on a nation-wide basis. Similarly we 
must strive to secure a greater measure of success in the enu- 
meration of the population at the child ages in the Census of 
1920. Accurate census returns of the child population of the 
United States, together with improved birth registration, 
the extension and refinement of death registration, and the 
critical statistical analysis of child mortality will place data 
at our disposal for practical service in the saving of child 
life, not only in infancy but at the ages of childhood as well. 



25 



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